WARD ROUND

Patientl-Awomanwith

Patientz - A womanwith a

numbnessof hands and feet

headache

AI Msusa, C Chibwana, H Mwandumba

AI Msusa, JJ Kumwenda

A24year-old Malawian woman was admitted to the Department of Medicine of Queen Elizabeth Central Hospital in January 2002 with the complaint of: intermittent numbness of hands and feet and sometimes of the lips, over a period of 5 months, and of: stiff and painful hands for 2 days prior to presentation. Systemic inquiry revealed heafi palpitations, dizziness, easy fatigability and intermittent episodesof diarrhoea over the same period of time. Her symptoms started after the birth of her third child by uncomplicated vaginal delivery in a hospital. She was a housewife with no significant previous medical or surgical history. During the time of her illness, she had taken courses of penicillin, co-trimoxazole and paracetamol. She had no known drug allergy. Examination revealed a woman of good nutritional status, apyrexial, without pallor, jaundice or cyanosis, and with no signs of immunosuppression. She looked weak and was slow in all her movements. The pulse rate was 62lmin (regular), breathing l8/min, temperature36"C,BP tzalrommllg.

A woman of about 50 years of age was admitted to the medical departmentat Queen Elizabeth Central Hospital inMarch2002, with a casualty (admission) diagnosis of: 'Malaria, rule out sepsis'. Ward admission review revealed a 2 weeks history of headache that was frontal, continuous and had progressed in severity over the period. The headachewas aggravatedon standing. There was no history of trauma, fever, diarrhoea or cough. She had vomited several times in the past week. She reported that she had recently lost vision in the left eye. Her relatives stated that the patient had occasionally passed urine in her clothes recently, and had sometimesactually raised her dressand micturated in public places. There was no history of hypertension,diabetesmellitus or shingles. She was married to a secondhusband,the first having died (causeunknown.;. Of her five children, three had died. She took no alcohol and was a non-smoker. On examination she was a well-nourished woman, in obvious pain from headache. She was well orientated as to person, place and time, but seemedsomewhatwithdrawn. The pulse rate was 48/min, regular, blood pressure 100/60 without postural fall, breathing rate 18/min, temperature36.8 C. There was no pallor, jaundice, cyanosis, lymphadenopathy, neck stiffness or oral candidiasis. She moved all limbs equally and could walk well. Pupils were equal and of normal size, reacting to light and accommodation. Her systemic examination reveled no abnormality.

While the blood pressure was being taken in her right arm, the right hand became stiff, with flexion at the wrist and extension of the fingers (see figures) Fig 1. Patient's arm before application ofblood-pressurecuff

'Malaria' is a common causeof headache. l I

1. Whatfeatures in this patient suggestthat there may be another causeof her headache? 2. What investigations are neededto reach a diagnosis? for discussion of these tvvopatients, seepage 30

Fig.2 after application of cufffor about 2 minutes

I. What condition does this woman have? 2. What are the possible causesof this condition? 3. What investigations must be done to reach to a definitive diagnosis? \lalawi Medical Jomal

WARD ROUND X-rays of spine and hands:normal. These results indicate a diagnosis of primary hypoparathyroidism as the causeof her hypocalcaemia,and the findings also DISCUSSION - Patient 1: indicate the presenceof primary hypothyriodism' A woman with numbness of hands and feet The commonest cause of hypoparathyroidism is surinadvertent removal of the parathyroid glands during gery This woman has tetany, characterisedby episodic numbnessor operation for goitre or thyrotoxicosis' There was no history of paraesthesiaeof the hands, feet and lips' sometimes with stiffsurgery in this patient. Primary hypoparathyroidsm is an nessor cramps. She has a positive Trousseau'ssign' with typiuncommon cause of hypocalcaemia. Primary hypoparathycal stiff posturing of the hand after inflation of a pressurisedcuff roidism may be associatedwith autoimmune conditions like perto the upper arm, and maintaining the pressureabovethe systolic nicious anaemia,hypothyroidism, adrenalfailure etc' In her case level for a few minutes. Important causesof tetany are hypocalprimary hypothyroidism was also found to be present: we had caemia and alkalosis, and managementrequires seeking which not suspectedthis clinically, but it is the likely explanation for ofthese is the cause,and what underlyingdiseaseis responsible her slownessof movements and her bradycardia' for the biochemical disorder. This combination of endocrine deficiencies suggestsa A feature that can sometimesbe found (but was absent diagnosis of polyglandular deficiency. Patients with a suspectin this patient) is Chvostek's sign - muscular contractions at the ed endocrine derangementneed to be fully investigatedboth for corners of the eyes or mouth induced when the facial nerve is the particular gland and for the other endocrine glands' lightly tapped with a finger or reflex hammer' just anterior to the The patient was prescribed combined Calcium and parotid gland. Vitamin D3 supplements and thyroxine tablets, and will be The commonestcauseof alkalotic tetany is overbreathregularlyas an outpatienl. ing (often through anxiety or hysteria). There was no evidence reviewed of this in this patient.

from page 29"'

Initial investigations were done with the following results: Full blood count Red cell morphology Plasma: Sodium Chloride Poiurriurn Calcium Phosphate

normal normal 138 100 3.6 5.0 9.5

Electrocardiogram findings --

(135 - 145) mmoVl (98 - 106)mmoUl

Sinus rhythm Rate 58 teats Per minute, regular Prolonged QT interval (0.48 sec) U waves

l. Renalinsfficiency - this is the commoneslcause 2. Hypoalbuminaemia-- eac! g/L decreasein serumalbumin decreasesserumCa--bY0.8 mgidl. 3. Hypoparathyroidi sm oid p r"uioohypoparathyroidism 4. uypimagnesaemia

si. i{"*,'" ij' i,fi, i"n y

6. Othercournv pancreatitis, sepsis,massivetransfusionof citrated blood and also iatrogenic in casesofpost surgery'

Further investigation of plasma samplesrevealed: (normal range0.5 - 1.5) mgldl 1.1 creatinine (8 - 25) mg/dl 22.3 nitrogen urea (6.0 - 8.0) g/dl 7.O protein total t 3 . 5- 5 ' 0 1 g / d l albumin 4.8 1 . 6- 2 . 3 )m s i e l z.v magneslum (l.l -7.7) Pmol/L 0.3 p*irho.-on. (0.4 - 6-2) mIUiL 9.6 TSH (0'69 - 2.02) nglrrn 0.14 T3 30

2.80

References (5th Edition). Mosby Inc 1. Feni FF: Practical Guide to the care o.f the Medical P(ttient 2001 St. Louis. London 2. Kumar P, Clark M (Eds ): Clinicql Medicine ({th Edition)' WB Saunders'1998 Medicine ( l|th 3. Fauci AS. Braunwald E, et al (Eds ): Harrison's Principles of lnternal Edition).Mccruw-Hill CompaniniesInc, 1998 St Louis'

(3.5 - 5.0) mmoVl (8.5 - 10.5)mg/dl (3.0 - a.5) mgidl

The findings (biochemical studies and ECG) confirmed a diagnosis of hypocalcaemia. Other notable findings were the high plasma phosphateconcentration and bradycardia. We considered the following possiblecausesof hypocalcaemia:

T4

A T Msusa', C Chibwana', H Mwandumba" 1 Intern, Dept of Medicine, QECFVCollege of Medicine Blantyre 2 Registrar, Dept of Medicine, College of Medicine Blantyre 3 Wellcome Trust/Dept of Medicine College of Medicine Blantyre

(4.8- I 1.8)ug/dl

- Patient2: DISCUSSION A woman with headache Four features in this patient suggest a cause for her headache other than malaria: 1. the continuous and progressive nature of the headache 2. her unilaterallossof vision 3. her loss of social inhibitions (micturating in public) 4. bradycardia In the ward the following diagnoseswere considered: headachesecondaryto increasedintracranial pressure cryptococcal meningitis frontal lobe lesion depression The peripheral blood film showed no malaria parasites and no trypanosomes.A full blood count was normal' The VDRL was non-reactive. A blood culture grew no bacterial or fungal pathogen. An ophthalmologist saw the patient and observed that the left optic disc had well-defined margins, was abnormally pale, with no cupping, and that normal vesselsemergedcentrally' A diagnosis was made of non-glaucomatous optic atrophy, probably due to long-standing compressionof the left optic nerve' Malawi Medical Jomal